Topics to Review

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Topics to Review

• Diffusion
• Skeletal muscle fiber (cell) anatomy
• Membrane potential and action potentials
• Action potential propagation
• Excitation-contraction coupling in skeletal
  muscle
• skeletal muscle action potential and molecular
  mechanism of skeletal muscle contraction
• Tetanus in skeletal muscle
• Norepinephrine, epinephrine and acetylcholine

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Cardiovascular System

• The cardiovascular system is a series of tubes
  (blood vessels) filled with blood connected to a
  pump (heart)
• Pressure generated in the heart continuously
  moves blood through the system which facilitates
  the transportation of substances throughout the
  body
• nutrients, water and gasses that enter the body
  from the external environment
• materials that move from cell to cell within the
  body
• wastes that the cells eliminate
• Blood vessels that carry blood away from the
  heart are called arteries, which carry blood to
  the exchange vessels called capillaries
• Blood flowing out of capillaries is returned back
  to the heart via blood vessels called veins

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Why Does Blood Flow?

• Fluids flow down pressure gradients (?P) from
  regions of higher pressures to regions of lower
  pressures
• Blood flows out of the heart when it contracts
  (region of highest pressure) into the closed loop
  of blood vessels (region of lower pressure)
• As blood moves through the cardiovascular system,
  a system of one way valves in the heart and veins
  prevent the flow of blood or reversing its
  direction of flow ensuring that blood flows in
  one direction only

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The Pump

• The heart is divided by a central wall (septum)
  into right an left halves, whereby each half
  functions as in independent pump
• the septum serves to separate oxygenated blood
  (left half) from deoxygenated blood (right half)
• each half consists of a superiorly positioned
  atrium and an inferiorly positioned ventricle
• the atrium receives blood returning to the heart
  from the blood vessels and the ventricle pumps
  blood out into the blood vessels

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Systemic Circulation

• The left side of the heart receives newly
  oxygenated blood from the lungs and pumps it
  through the systemic circulation
• from the left atrium, blood flows into the left
  ventricle and then is pumped into the aorta which
  branch into smaller arteries to bring blood to
  systemic capillaries all over the body for
  exchange
• the first branch is the coronary artery which
  nourishes the heart itself
• from the systemic capillaries, blood flows into
  veins
• veins from the upper part of the body join to
  form the superior vena cava
• veins from the lower part of the body join to
  form the inferior vena cava
• blood from the capillaries of the heart flow into
  the coronary vein which empties into the right
  atrium
• these veins empty into the right atrium

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Pulmonary Circulation

• The right side of the heart receives blood from
  the tissues and pumps it through the pulmonary
  circulation
• from the right atrium, blood flows into the right
  ventricle and then is pumped into the pulmonary
  trunk
• the pulmonary trunk divides into right and left
  pulmonary arteries which branch into smaller
  arteries to bring blood to pulmonary capillaries
  in the lungs for gas exchange
• from the pulmonary capillaries, blood flows to
  the left atrium through the pulmonary veins

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Heart Shape and Position

• The heart is a muscular organ roughly the size of
  a fist
• The pointed apex of the heart angles down to the
  left side of the body and rests on the diaphragm
• The broad base lies just behind the sternum

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Heart Covering

• The heart is surrounded by a double membrane
  pericardium made of connective tissue
• prevents overfilling of the heart with blood
• Parietal pericardium
• fits loosely around the heart
• attached to the superficial surface of the
  diaphragm
• Visceral pericardium or epicardium
• thin superficial layer of the heart
• Pericardial cavity
• filled with pericardial fluid
• allows for the heart to work in a relatively
  friction-free environment
• inflammation of the pericardium called
  pericarditis may reduce the lubrication

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Heart Wall

• The heart is composed mostly of cardiac muscle
  (or myocardium) which is covered by thin outer
  and inner layers of connective tissue (epicardium
  or visceral layer of the pericardium) and
  epithelial tissue (endocardium), respectively
• The myocardium of the 2 atria and 2 ventricles
  contract (systole) and relax (diastole) in a
  coordinated fashion to pump blood through the
  pulmonary and systemic circulations
• first the atria contract together (while the
  ventricles relax), then the ventricles contract
  together (while the atria relax)
• this pattern repeats each heartbeat in what is
  called the cardiac cycle

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Pericardium and Heart Wall
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How Does the Heart Move Blood?

• Blood can flow in the cardiovascular system if
  one region develops higher pressure than other
  regions
• The ventricles are responsible for creating a
  region of high pressure
• When the blood filled ventricles undergo systole,
  the pressure exerted on the blood increases and
  blood flows out of (empties) the ventricles into
  the arteries displacing the lower pressure blood
  in the vessels
• as blood moves through the vasculature, pressure
  is lost due to friction between the blood and the
  walls of the vessels
• When the blood filled ventricles undergo
  diastole, the pressure exerted on the blood
  decreases and blood flows into (fills) the
  ventricles
• The filled ventricle undergoes systole again and
  repressurizes the blood

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Heart Valves

• The heart contains 2 pairs of valves (4) which
  ensure a unidirectional blood flow through the
  heart
• 2 atrioventricular valves are located between the
  atria and ventricles
• 2 semilunar valves are located between the
  ventricles and the arteries
• An open valve allows blood flow
• A closed valve prevents blood flow
• A valve will open and close due to a blood
  pressure gradient across it

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Atrioventricular Valves

• Atrioventricular (AV) valves prevent the backflow
  of blood from the ventricles into the atria
• Formed from thin flaps of tissue joined at the
  base to a connective tissue ring
• right AV valve has 3 flaps tricuspid
• left AV valve has 2 flaps bicuspid or mitral
  valve
• The valves move passively when flowing blood
  pushes on them during ventricular systole and
  diastole
• during ventricular systole, blood pushes against
  the bottom side of the AV valves and forces them
  upward into a closed position producing the first
  heart sound (lub)
• during ventricular diastole, blood pushes against
  the top side of the AV valves and forces them
  downward into an opened position which
  facilitates ventricular filling

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Chordae Tendineae and Papillary Muscles

• Flaps of the AV valves connect on the ventricular
  side to collagenous tendons called chordae
  tendineae
• The opposite ends of the chordae tendineae are
  tethered to finger-like extensions of the
  ventricular myocardium called papillary muscles
• these muscles provide stability for the chordae
  tendineae but cannot actively open or close the
  AV valves
• During ventricular systole, the chordae tendineae
  prevent the valve from being pushed back into the
  atrium
• If the chordae tendineae fail the valve is pushed
  back into the atrium during ventricular systole
  and is referred to a prolapse

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Semilunar Valves

• The semilunar valves separate the ventricles from
  the major arteries and prevent the backflow of
  blood from the major arteries to the ventricles
• each semilunar valve has 3 cuplike leaflets
• left semilunar valve aortic semilunar valve
• right semilunar valve pulmonary semilunar valve
• The valves move passively when flowing blood
  pushes on them during ventricular systole and
  diastole
• during ventricular systole, blood pushes against
  the bottom side of the semilunar valves and
  forces them upward into an opened position which
  facilitates ventricular ejection
• during ventricular diastole, blood pushes against
  the top side of the semilunar valves valves and
  forces them downward into a closed position
  producing the second heart sound (dup)

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The Myocardium

• Most of the myocardium is contractile
  (contractile or working cardiac myocytes), but
  about 1 of the myocardial cells are specialized
  to spontaneously generate action potentials
  (autorhythmic or conducting cardiac myocytes)
• These cells allow the heart to beat without any
  outside signal because the signal for contraction
  occurs within the heart muscle itself (myogenic)
• Autorhythmic myocytes
• initiate action potentials which cause
  contraction of contractile cardiac muscle fibers
  (act like a neuron)
• aka pacemakers since they set the rate of the
  heartbeat
• DO NOT contract (lack sufficient actin and myosin)

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The Myocardium

• Contractile cardiac muscle fibers are in some
  ways similar to and in other ways different than
  skeletal muscle fibers
• smaller than skeletal muscle fibers with 1
  nucleus
• striated (contains sarcomeres of actin and
  myosin)
• myocardial sarcoplasmic reticulum is smaller than
  skeletal muscle, reflecting the fact that cardiac
  muscle depends on extracellular Ca2 to initiate
  contraction
• mitochondria occupy 30 of the cell volume which
  demonstrates the high energy demand of these
  cells
• in person at rest, hemoglobin unloads 75 of its
  delivered oxygen to cardiac muscle
• individual cells branch and join neighboring
  cells end-to end at junctions called intercalated
  disks

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Intercalated Disks

• Consist of desmosomes and gap junctions
• desmosomes are protein complexes that bind
  adjacent cells together allowing force generated
  in one cell to be transferred to the adjacent
  cell
• gap junctions are protein complexes that form
  pores between adjacent cells which electrically
  connecting adjacent cells to one another as ions
  are able to pass freely between cells (electrical
  synapse)
• allow waves of depolarization to spread rapidly
  from cell to cell so that the heart muscle cells
  contract almost simultaneously
• an AP in one myocyte of the heart will spread to
  adjacent myocytes until every myocyte of the
  heart elicits an AP

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E-C of Contractile Cardiac Myocytes

• Just like skeletal muscle fibers, contractile
  cardiac myocytes will contract in response to an
  action potential in the cell
• note that the electrical event (AP) in the cell
  ALWAYS causes the mechanical event (contraction)
  and is called excitation-contraction coupling (to
  join)
• The action potential in cardiac myocytes
  originates in spontaneously in the autorhythmic
  cells and spreads into contractile cells through
  gap junctions

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E-C of Contractile Cardiac Myocytes

• An action potential that propagates into the
  t-tubules opens voltage-gated Ca2 channels and
  Ca2 enters the cell
• The Ca2 that diffuses into the sarcoplasm binds
  to and opens Ca2 channels in the of the
  sarcoplasmic reticulum (SR) membrane causing
  stored Ca2 in the SR to move into the sarcoplasm
  creating a Ca2 spark
• known as calcium induced calcium release (CICR)
• multiple sparks summate to create a Ca2 signal
• Ca2 from the SR provides 90 of the Ca2 needed
  for contraction, the other 10 comes from the ECF
• Ca2 diffuses through the cytosol to the
  contractile elements and promotes the interaction
  between actin and myosin (crossbridge cycling)
  resulting in the contraction (systole) of the cell

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Relaxation of a Working Cardiac Myocyte

• Removal of the Ca2 from the sarcoplasm results
  in the relaxation (diastole) of the cell
• Ca2 is removed from the sarcoplasm and returned
  to the SR and ECF
• Ca2-ATPase (primary active transporting protein)
  in the SR membrane pumps Ca2 out of the
  sarcoplasm back into the SR (via ATP hydrolysis)
  to be ready for the next heart beat
• Na, Ca2-exchanger (secondary active
  transporting protein) in the sarcolemma which
  actively transports Ca2 out of the sarcoplasm as
  Na diffuses into the sarcoplasm

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Force of Cardiac Muscle Contraction

• The amount of force that a cardiac fiber
  generates can vary and depends on 2 key factors
• the amount of Ca2 in the cytosol during
  contraction
• determines the number of active crossbridges
  formed during contraction
• when cytosolic concentrations of Ca2 are low,
  fewer crossbridges are activated and the force of
  contraction is small
• when additional Ca2 enters the cell from the
  ECF, more Ca2 is released from the SR activating
  more crossbridges increasing the force of
  contraction
• length of the fiber before contraction
• stretching a fiber before it contracts results in
  a greater the force of contraction

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Contractile vs. Autorhythmic Action Potentials

• Each of the 2 types of myocytes has a distinctive
  AP
• The action potential of both cardiac myocytes
  results from the opening and closing of
  voltage-gated ion channels in the cell membrane
  (sarcolemma) and the resultant diffusion of ions
  either into or out of the cell
• The membrane potential of a working myocyte is
  maintained at a stable resting value (-90 mV)
  until it is stimulated by an action potential
  from an adjacent cell
• The ability of autorhythmic cells to
  spontaneously generate action potentials results
  from their unstable membrane potential that
  begins at its lowest value (-60 mV) and slowly
  depolarizes toward threshold
• aka the pacemaker potential since it never
  rests
• When the cell reaches threshold, the cell fires
  an AP

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Contractile Myocyte Action Potential

• The action potential has 5 distinct phases
• 0. Rapid depolarization due to the opening of
  voltage gated Na channels (inward Na flux)
• 1. Slight repolarization due to closing of
  voltage gated Na channels (inward Na flux
  stops)
• 2. Plateau phase due to the opening of voltage
  gated Ca2 channels (inward Ca2 flux)
• 3. Repolarization phase due to the opening of
  voltage gated K channels (outward K flux) and
  closing of voltage gated Ca2 channels (inward
  Ca2 flux stops)
• 4. Resting phase due to the voltage-gated
  channels being closed
• The influx of Ca2 during the plateau phase
  lengthens the duration of the AP and the
  refractory period

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• The refractory period of the action potential is
  nearly as long as its contractile period
• this prevents twitch summation and tetany of the
  working cardiac myocytes

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Autorhythmic Myocyte Action Potential

• When the cell membrane potential is at -60 mV,
  voltage-gated If channels that are permeable to
  Na open and allow Na to slowly diffuse into the
  cell depolarizing the cell towards threshold
• Just before threshold is reached, the If channels
  close, and the depolarization due to Na influx
  causes voltage-gated Ca2 channels to open which
  causes Ca2 to diffuse into the cell bringing the
  cell to threshold and opening up more
  voltage-gated Ca2 channels
• At the peak of the AP, voltage-gated Ca2
  channels close and voltage-gated K channels
  open, which repolarize the cell back to -60 mV

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The Heart as a Pump

• In order for individual myocardial cells to
  produce enough force to move blood around the
  cardiovascular system they must depolarize and
  contract in a coordinated fashion
• The heart beat is initiated by an action
  potential in an autorhythmic cell that rapidly
  spreads to adjacent cells through gap junctions
  in the intercalated disks
• The wave of depolarization that sweeps though the
  entire heart is followed by a wave contraction
  that passes across the atria and then move into
  the ventricles

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Wave of Depolarization

• The electrical signal for contraction begins as
  the sinoatrial (SA) node fires an action
  potential
• a small group of autorhythmic cells in the wall
  of the right atrium that serves as the hearts
  pacemaker
• From the SA node, the AP propagates via gap
  junctions to the contractile cells of the atria,
  causing atrial systole and through branched
  internodal fibers to the atrioventricular node
  (group of autorhythmic cells at the boundary
  between the right atrium and the interventricular
  septum)
• only route for the AP to spread into the
  ventricles (fibrous skeleton at junction between
  atria and ventricles prevent transfer of electric
  signals)
• slows down the speed of the AP propagation
• ensure that the atria contract BEFORE the
  ventricles contract

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Wave of Depolarization

• The AP propagates from the AV node to the Bundle
  of His (and bundle branches)
• located within the interventricular septum
• speeds up the speed of the AP propagation
• propagates the AP from the AV node through the
  interventricular septum to the apex of the heart
  to the Purkinjie fibers
• located within the interventricular septum and
  the walls of the right and left ventricles
• propagates the AP from the bundle branches to the
  contractile cells of the ventricles within the
  interventricular septum and the outer walls of
  the right and left ventricles, causing
  ventricular systole

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Electrocardiogram

• The electrocardiogram (ECG) is a graphical
  representation of the summation of the APs in the
  heart
• relates the depolarization and repolarization of
  the atria and the ventricles with respect to time
• since depolarization initiates contraction, these
  electrical events can be associated with the
  systole and diastole of the heart chambers
• The 3 major electrical events of an ECG repeat
  each time the SA node fires an action potential
  which also results in a single contraction-relaxat
  ion cycle of the heart known as the cardiac cycle

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ECG Waves

• There are 3 major waves of the ECG which, follow
  in sequence, the spread of the AP from the SA
  node to the ventricles
• P wave
• simultaneous depolarization of both atria
• QRS Complex
• depolarization of both ventricles
• the repolarization both atria occurs at this time
  but is hidden by much larger ventricular
  depolarization
• T wave
• repolarization of all both ventricles
• The mechanical events of the cardiac cycle lag
  slightly behind the electrical signals just as
  the contraction of a single muscle cell follows
  its action potential

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ECG
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The Mechanical Events of the Cardiac Cycle

• The cardiac cycle has 5 phases which are
  associated with the blood pressure and blood
  volume changes that occur within the ventricles
  during ventricular diastole and systole
• 1. Passive ventricular filling
• 2. Atrial systole
• 3. Isovolumetric contraction
• 4. Ventricular ejection
• 5. Isovolumetric relaxation

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Passive Ventricular Filling

• At the beginning of ventricular filling, the
  semilunar valves are closed, BOTH atria and
  ventricles are in diastole whereby blood from the
  great veins pass through the atria through opened
  AV valves passively filling the ventricles
  (accounts for 85 of ventricular filling)

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Atrial Systole

• The P wave of the ECG causes atrial systole
  whereby blood is ejected from the atria to finish
  the filling of the diastolic ventricles (accounts
  for 15 of ventricular filling)
• The volume of blood in each ventricle at the end
  of the filling phase is called End Diastolic
  Volume (EDV) and is approximately 135 mL

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Isovolumetric Contraction

• As atrial systole comes to an end the QRS complex
  of the ECG causes ventricular systole, which
  begins with a short isovolumetric phase
• The semilunar valves remain closed while
  ventricular pressure rises above atrial pressure
  causing the AV valves to close (lub)
• the ventricle becomes a closed chamber with no
  blood entering or leaving the ventricle as
  contraction continues to further increase the
  pressure in the ventricles

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Ventricular Ejection

• Ventricular pressure continues to rise until it
  overcomes the pressure in the arteries opening
  the semilunar valves and ejecting blood into the
  arteries
• Approximately 70 mL of the blood in the ventricle
  is ejected (stroke volume) which leaves 65 mL of
  blood remaining in the ventricles (End Systolic
  Volume (ESV))

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Left vs. Right Ventricle

• The left and the right ventricles pump the same
  volume of blood into the systemic and pulmonary
  circuits but at very different pressures (120
  mmHg vs. 25 mmHg)
• Because the blood that is ejected from the left
  ventricle has a further distance to travel (head
  to toes), the outer wall of the left ventricle is
  notably thicker (more myocardium) than the right
  which, when contracted, produces a higher blood
  pressure capable of moving blood a greater
  distance.

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Isovolumetric Relaxation

• Ventricular contraction comes to an end, whereby
  ventricular pressure becomes less than the
  pressure in the great arteries causing a backflow
  of blood into the ventricles closing the
  semilunar valves (dup)
• semilunar valve closure causes a brief rise in
  the arterial pressure called the dicrotic notch
  as blood rebounds off the valve
• Following the closure of the semilunar valves,
  the ventricles once again become closed chambers
  with no blood entering or leaving, as the AV
  valves remain closed.
• As the ventricles continue to relax, the pressure
  continues to fall in until it becomes less than
  the pressure in the atria causing the AV valves
  to open which ends isovolumetric relaxation and
  begins passive ventricular filling

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Cardiac Cycle
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Cardiac Output (CO)

• CO is the volume of blood pumped by a single
  ventricle in one minute and is a measure of the
  cardiac performance
• Directly related to both the heart rate (HR) and
  stroke volume (SV)
• HR is the number of heart beats per minute
• normal resting HR 75 beats/min
• SV is the volume of blood ejected out by a
  ventricle each systole (beat) EDV - ESV
• normal resting SV 70 ml/beat
• HR x SV CO
• (75 beats/min) x (70 ml/beat) 5250 ml/min
• 5.25 L/min
• the entire blood volume is completely circulated
  around the body every minute
• During exercise CO can increase to 30 L/min

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The Need to Control Cardiac Output

• The CO can be altered to meet the needs of your
  body
• deliver O2, nutrients, hormones to the cells of
  the body as quickly as they are used
• remove CO2, urea, lactic acid from the cells of
  the body as quickly as they are produced
• At certain times, the needs of your body change
• skeletal muscles during exercise use O2 and
  produce CO2 faster requiring an increase in the
  delivery rate of O2 and removal rate of CO2
• during sleep, O2 is used and CO2 is produced more
  slowly requiring a decrease in the delivery rate
  of O2 and removal rate of CO2

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Alteration of Cardiac Output

• CO can be changed by either changing HR or SV
• If HR or SV increases, the CO increases, sending
  blood through the cardiovascular system faster
• If HR or SV decreases, the CO decreases, sending
  blood through the cardiovascular system slower
• Both HR and SV are controlled by the 2
  antagonistic branches of the Autonomic Nervous
  System
• Cardioacceleratory (sympathetic) center in the
  medulla oblongata can increase both the HR and SV
• Cardioinhibitory (parasympathetic) center in the
  medulla oblongata can decrease the HR only

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Resting Heart Rate

• In a resting adult the SA node initiates an AP
  approximately every 0.8 seconds (75 per minute)
  determining the frequency (sinus rhythm) of
  systole and diastole of the atria and ventricles
  resulting in a heart rate of 75 beats per minute
  (bpm)
• The frequency of the APs can be altered by the
  antagonistic branches of the ANS to raise or
  lower the heart rate (HR) when appropriate
• the Sympathetic NS increases HR from rest
• when HR gt 100 bpm tachycardia
• the Parasympathetic NS decreases HR from rest
• when HR lt 60 bpm bradycardia

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Cardiac Centers and Regulation of HR

• APs from the cardioacceleratory center propagate
  along the sympathetic cardiac nerve which synapse
  with the SA node
• sympathetic neurons exocytose norepinepherine (an
  adrenergic agent) onto the SA node
• norepinephrine binds to ß-(beta) adrenergic
  receptors of SA nodal cells resulting in an
  increase in the frequency of APs in the SA node
• APs from the cardioinhibitory center propagate
  along the Vagus nerve which synapses with the SA
  node
• releases the neurotransmitter acetylcholine (a
  cholinergic agent) onto the SA node
• acetylcholine binds muscarinic cholinergic
  receptors of SA nodal cells resulting in a
  decrease in the frequency of APs in the SA node

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Regulation of SV

• Ventricular contractility
• the force produced by the working ventricular
  myocytes during systole
• controlled by hormones, neurotransmitters and
  other chemical substances (drugs)
• The preload on the ventricles
• the force applied to working ventricular myocytes
  before they contract
• the amount of pressure in the ventricles at the
  end of ventricular filling
• aids ejection of blood out of the ventricles
• The afterload on the ventricles
• the force applied to working ventricular myocytes
  after they begin to contract
• the amount of pressure in the arteries pushing on
  the closed semilunar valves
• opposes ejection of blood out of the ventricles

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Ventricular Contractility and SV

• The force produced by a single working
  ventricular myocyte depends upon the amount of
  sarcoplasmic Ca2 during systole
• large intracellular Ca2 levels ? strong systole
  ? larger SV
• small intracellular Ca2 levels ? weak systole ?
  smaller SV
• certain hormones and drugs can alter the amount
  of intracellular Ca2 in working myocytes during
  systole

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Chemical Effects on Ventricular Contractility

• Epinephrine and norepinephrine bind to
  b-adrenergic receptors on working myocytes
  causing the opening of additional Ca2 channels
  in the cell membrane
• increases sarcoplasmic Ca2 increasing the SV
• b blockers prevent the binding to the b
  receptors
• decreases intracellular Ca2 decreasing the SV
• Cardiac glycosides (digoxin/digitalis) inhibits
  the Na,K-ATPase decreasing the Na gradient
  across the cell membrane of the myocyte
• decreases the removal of Ca2 from the sarcoplasm
  by the Na,Ca2-exchanger
• increases intracellular Ca2 increasing the SV

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Preload, the Starling Law of the Heart and SV

• The more working ventricular cardiac myocytes are
  stretched, the harder they contract. This
  stretch is determined by the amount of blood in
  the ventricle before it contracts (EDV).
• If the EDV increases the SV will increase
• If the EDV decreases the SV will decrease
• The amount of blood that enters the ventricle
  during filling depends on factors such as venous
  pressure, blood volume and atrial contractility

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Afterload and the SV

• Arterial blood pressure opposes the ejection of
  blood from the ventricles by pushing against
  closed semilunar valves
• The afterload and the SV are inversely
  proportional
• if the afterload increases the SV decreases
• if the afterload decreases the SV increases
• The arterial blood pressure depends on factors
  such as blood volume, arterial compliance and
  arterial vasoconstriction/vasodilation